Subglottic secretion drainage in prevention of ventilator-associated pneumonia: mind the gap between studies and reality

Despite application of preventive measures in bundles, ventilator-associated pneumonia (VAP) remains the most common nosocomial infection, leading to increases in mechanical ventilation duration, ICU stay and healthcare costs [1]. Although two meta-analyses report a half reduction of VAP following use of endotracheal tubes (ETTs) with subglottic secretion drainage (SSD) [2], these devices are not widely employed in clinical practice. Although ETTs with SSD are more expensive, Kelley demonstrates from statistical analyses that these devices could represent health savings [3]. Management of patients intubated before admission to ICU and requiring prolonged mechanical ventilation (≥72 hours) is another concern. This large subgroup is usually excluded from studies evaluating ETTs with SSD even though they may benefit from these devices [4]. In the French IPREA multicenter prospective trial assessing discomforts perceived by 1,380 unselected patients admitted to 14 ICUs between March and November 2005, 869 (63%) patients required intubation and mechanical ventilation. Of these, 541 (62%) were intubated before ICU admission, representing 3,001 (50%) of 5,971 days of mechanical ventilation [5]. This proportion is 48% when only patients requiring 72 h of mechanical ventilation or more are considered. In the IPREA 2 study, of 1,643 patients admitted to 17 French ICUs between March and November 2008 (personal unpublished data), 1,064 (64.8%) were mechanically ventilated. Of the 7,857 days of mechanical ventilation, 54% occurred while the patients were intubated before ICU admission. This proportion is 45% in patients requiring at least 72 hours of mechanical ventilation.